Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Acute abdominal and pelvic pain in pregnancy: ESUR recommendations


Acute abdominal pain in pregnancy presents diagnostic and therapeutic challenges. Standard imaging techniques need to be adapted to reduce harm to the fetus from X-rays due to their teratogenic and carcinogenic potential. Ultrasound remains the primary imaging investigation of the pregnant abdomen. Magnetic resonance imaging (MRI) has been shown to be useful in the diagnosis of gynaecological and obstetric problems during pregnancy and in the setting of acute abdomen during pregnancy. MRI overcomes some of the limitations of ultrasound, mainly the size of the gravid uterus. MRI poses theoretical risks to the fetus and care must be taken to minimise these with the avoidance of contrast agents. This article reviews the evolving imaging and clinical literature on appropriate investigation of acute abdominal and pelvic pain during established intrauterine pregnancy, addressing its common causes. Guidelines based on the current literature and on the accumulated clinico-radiological experience of the European Society of Urogenital Radiology (ESUR) working group are proposed for imaging these suspected conditions.

Key Points

Ultrasound and MRI are the preferred investigations for abdominal pain during pregnancy.

Ultrasound remains the primary imaging investigation because of availability and portability.

MRI helps differentiate causes of abdominopelvic pain when ultrasound is inconclusive.

If MRI cannot be performed, low-dose CT may be necessary.

Following severe trauma, CT cannot be delayed because of radiation concerns.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Fig. 3
Fig. 4


  1. 1.

    Sharp HT (2002) The acute abdomen during pregnancy. Clin Obstet Gynecol 45:405–413

  2. 2.

    Cappell MS, Friedel D (2003) Abdominal pain during pregnancy. Gastroenterol Clin N Am 32:1–58

  3. 3.

    Stone K (2002) Acute abdominal emergencies associated with pregnancy. Clin Obstet Gynecol 45:553–561

  4. 4.

    Sharp HT (1994) Gastrointestinal surgical conditions during pregnancy. Clin Obstet Gynecol 37:306–315

  5. 5.

    Kilpatrick CC, Monga M (2007) Approach to the acute abdomen in pregnancy. Obstet Gynecol Clin N Am 34:389–402

  6. 6.

    Kilpatrick CC, Orejuela FJ (2008) Management of the acute abdomen in pregnancy: a review. Curr Opin Obstet Gynecol 20:534–539

  7. 7.

    Augustin G, Majerovic M (2007) Non-obstetrical acute abdomen during pregnancy. Eur J Obstet Gynecol Reprod Biol 131:4–12

  8. 8.

    Barloon TJ, Brown BP, Abu-Yousef MM et al (1995) Sonography of acute appendicitis in pregnancy. Abdom Imaging 20:149–151

  9. 9.

    Kanal E, Barkovich AJ, Bell C et al (2007) ACR guidance document for safe MR practices: 2007. AJR Am J Roentgenol 188:1–27

  10. 10.

    De Wilde JP, Rivers AW, Price DL (2005) A review of the current use of magnetic resonance imaging in pregnancy and safety implications for the fetus. Prog Biophys Mol Biol 87:335–353

  11. 11.

    Kaakaji Y, Nghiem HV, Nodell C et al (2000) Sonography of obstetric and gynecologic emergencies: Part I. Obstetric emergencies. AJR Am J Roentgenol 174:641–649

  12. 12.

    Derchi LE, Serafini G, Gandolfo N, Gandolfo NG, Martinoli C (2011) Ultrasound in gynecology. Eur Radiol 11:2137–2155

  13. 13.

    Pedrosa I, Rofsky NM (2003) MR imaging in abdominal emergencies. Radiol Clin N Am 41:1243–1273

  14. 14.

    Austin LM, Frush DP (2001) Compendium of national guidelines for imaging the pregnant patient. AJR Am J Roentgenol 197:W737–46

  15. 15.

    Katz DS, Klein MA, Ganson G, Hines JJ (2012) Imaging of abdominal pain in pregnancy. Radiol Clin North Am 50:149–171

  16. 16.

    Beddy P, Keogan MT, Sala E, Griffin N (2010) Magnetic resonance imaging for the evaluation of acute abdominal pain in pregnancy. Semin Ultrasound CT MR 31:433–441

  17. 17.

    Oto A, Ernst RD, Ghulmiyyah LM et al (2009) MR imaging in the triage of pregnant patients with acute abdominal and pelvic pain. Abdom Imaging 34:243–250

  18. 18.

    Birchard KR, Brown MA, Hyslop WB, Firat Z, Semelka RC (2005) MRI of acute abdominal and pelvic pain in pregnant patients. AJR Am J Roentgenol 184:452–458

  19. 19.

    Masselli G, Brunelli R, Casciani E et al (2011) Acute abdominal and pelvic pain in pregnancy: MR imaging as a valuable adjunct to ultrasound? Abdom Imaging 36:596–603

  20. 20.

    Miller DL (2008) Safety assurance in obstetrical ultrasound. Semin Ultrasound CT MR 29:156–164

  21. 21.

    Kanal E, Barkovich AJ, Bell C et al (2007) ACR Blue Ribbon Panel on MR Safety. ACR guidance document for safe MR practices: 2007. AJR Am J Roentgenol 188:1447–1474

  22. 22.

    American College of Radiology (2008) ACR practice guideline for imaging pregnant or potentially pregnant adolescents and women with ionizing radiation. Accessed 21 Feb 2010

  23. 23.

    DeWilde JP, Rivers AW, Price DL (2005) A review of the current use of magnetic resonance imaging in pregnancy and safety implications for the fetus. Prog Biophys Mol Biol 87:335–353

  24. 24.

    Huisman TA (2008) Fetal magnetic resonance imaging. Semin Roentgenol 43:314–336

  25. 25.

    Hand JW, Li Y, Hajnal JV (2010) Numerical study of RF exposure and the resulting temperature rise in the foetus during a magnetic resonance procedure. Phys Med Biol 55:913–930

  26. 26.

    Gowland PA, De Wilde J (2008) Temperature increase in the fetus due to radio frequency exposure during magnetic resonance scanning. Phys Med Biol 53:L15–L18

  27. 27.

    Pugash D, Brugger PC, Bettelheim D, Prayer D (2008) Prenatal ultrasound and fetal MRI: the comparative value of each modality in prenatal diagnosis. Eur J Radiol 68:214–226

  28. 28.

    Yang L, Krefting I, Gorovets A et al (2012) Nephrogenic systemic fibrosis and class labeling of gadolinium-based contrast agents by the Food and Drug Administration. Radiology 265:248–253

  29. 29.

    Webb JA, Thomsen HS, Morcos SK (2005) The use of iodinated and gadolinium contrast media during pregnancy and lactation. Eur Radiol 15:1234–1240

  30. 30.

    American College of Obstetricians and Gynecologists (2009) ACOG committee opinion no. 299. Guidelines for diagnostic imaging during pregnancy. Obstet Gynecol 104:647–651

  31. 31.

    Thomsen HS, Morcos SK, Almén T et al (2013) Nephrogenic systemic fibrosis and gadolinium-based contrast media: updated ESUR Contrast Medium Safety Committee guidelines. Eur Radiol 23:307–318

  32. 32.

    Lazarus E, Mayo-Smith WW, Mainiero MB, Spencer PK (2007) CT in the evaluation of nontraumatic abdominal pain in pregnant women. Radiology 244:784–790

  33. 33.

    Sudah M, Vanninen RL, Partanen K et al (2002) Patients with acute flank pain: comparison of MR urography with unenhanced helical CT. Radiology 223:98–105

  34. 34.

    Patel SJ, Reede DL, Katz DS, Subramaniam R, Amorosa JK (2007) Imaging the pregnant patient for nonobstetric conditions: algorithms and radiation dose considerations. Radiographics 27:1705–1722

  35. 35.

    Tremblay E, Thérasse E, Thomassin-Naggara I, Trop I (2012) Quality initiatives: guidelines for use of medical imaging during pregnancy and lactation. Radiographics 32:897–911

  36. 36.

    Bourjeily G, Chalhoub M, Phornphutkul C, Alleyne TC, Woodfield CA, Chen KK (2010) Neonatal thyroid function: effect of a single exposure to iodinated contrast medium in utero. Radiology 256:744–750

  37. 37.

    Francois KE, Foley MR (2010) Antepartum and postpartum hemorrhage. In: Gabbe SG, Niebyl JR, Simpson JL (eds) Obstetrics: normal and problem pregnancies, 5th edn. Elsevier, Philadelphia, pp 458–462

  38. 38.

    Oyelese Y, Ananth CV (2006) Placental Abruption. Obstet Gynecol 108:1005–1016

  39. 39.

    Nyberg DA, Cyr DR, Mack LA, Wilson DA, Shuman WP (1987) Sonographic spectrum of placental abruption. AJR Am J Roentgenol 148:161–164

  40. 40.

    Sholl S (1987) Abruptio placentae: clinical management in non acute cases. Am J Obstet Gynecol 156:40–51

  41. 41.

    Glantz C, Purnell L (2002) Clinical utility of sonography in the diagnosis and treatment of placental abruption. J Ultrasound Med 21:837–840

  42. 42.

    Jaffe MH, Schoen WC, Silver TM, Bowerman RA, Stuck KJ (1981) Sonography of abruptio placentae. AJR Am J Roentgenol 137:1049–1054

  43. 43.

    Yeo L, Ananth C, Vintzileos A (2004) Placenta abruption. In: Sciarra J (ed) Gynecology and obstetrics. Lippincott, Williams & Wilkins, Hagerstown

  44. 44.

    Harris RD, Cho C, Wells WA (1996) Sonography of the placenta with emphasis on pathological correlation. Semin Ultrasound CT MR 17:66–89

  45. 45.

    Nyberg DA, Mack LA, Benedetti TJ, Cyr DR, Schuman WP (1987) Placental abruption and placental hemorrhage: correlation of sonographic findings with fetal outcome. Radiology 164:357–361

  46. 46.

    Nguyen D, Nguyen C, Yacobozzi M, Bsat F, Rakita D (2012) Imaging of the Placenta with pathologic correlation. Semin Ultrasound CT MRI 33:65–77

  47. 47.

    Masselli G, Brunelli R, Parasassi T, Perrone G, Gualdi G (2011) Magnetic resonance imaging of clinically stable late pregnancy bleeding: beyond ultrasound. Eur Radiol 21:1841–1849

  48. 48.

    Masselli G, Brunelli R, Di Tola M, Anceschi M, Gualdi G (2011) MR imaging in the evaluation of placental abruption: correlation with sonographic findings. Radiology 259:222–230

  49. 49.

    Atlas SW, Thulborn KR (2009) Intracranial hemorrhage. In: Atlas SW (ed) Magnetic resonance imaging of the brain and of the spine, 4th edn. Lippincott Williams & Wilkins, Philadelphia, pp 644–694

  50. 50.

    Wei SH, Helmy M, Cohen AJ (2009) CT evaluation of placental abruption in pregnant trauma patients. Emerg Radiol 16:365–373

  51. 51.

    Khong TY (2008) The pathology of placenta accreta, a worldwide epidemic. J Clin Pathol 61:1243–1246

  52. 52.

    Wu S, Kocherginsky M, Hibbard JU (2005) Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol 192:1458–1461

  53. 53.

    Wong HS, Hutton J, Zuccollo J, Tait J, Pringle KC (2008) Maternal outcome in placenta accreta: the significance of antenatal diagnosis and non-separation of placenta at delivery. N Z Med J 121:30–38

  54. 54.

    Finberg HJ, Williams JW (1992) Placenta accreta: prospective sonographic diagnosis in patients with placenta previa and prior cesarean section. J Ultrasound Med 11:333–339

  55. 55.

    Comstock CH, Love JJ, Bronsteen RA et al (2004) Sonographic detection of placenta accreta in the second and third trimesters of pregnancy. Am J Obstet Gynecol 190:1135–1140

  56. 56.

    Ito T, Katagiri C, Ikeno S, Takahashi H, Nagata N, Terakawa N (1999) Placenta previa increta penetrating the entire thickness of the uterine myometrium: ultrasonographic and magnetic resonance imaging findings. J Obstet Gynaecol Res 25:303–307

  57. 57.

    Lerner JP, Deane S, Timor-Trisch IE (1995) Characterization of placenta accreta using transvaginal sonography and color Doppler imaging. Ultrasound Obstet Gynecol 5:198–201

  58. 58.

    Shih JC, Palacios JM, Su YN et al (2009) Role of three-dimensional power Doppler in the antenatal diagnosis of placenta accreta: comparison with gray-scale and color Doppler techniques. Ultrasound Obstet Gynecol 33:193–203

  59. 59.

    Derman AY, Nikac V, Haberman S, Zelenko N, Opsha O, Flyer M (2011) MRI of placenta accreta: a new imaging perspective. AJR Am J Roentgenol 197:1514–1521

  60. 60.

    Palacios Jaraquemada JM, Bruno CH (2005) Magnetic resonance imaging in 300 cases of placenta accreta: surgical correlation of new findings. Acta Obstet Gynecol Scand 84:716–724

  61. 61.

    Warshak CR, Eskander R, Hull AD et al (2006) Accuracy of ultrasonography and magnetic resonance imaging in the diagnosis of placenta accreta. Obstet Gynecol 108:573–581

  62. 62.

    Lax A, Prince MR, Mennitt KW, Schwebach JR, Budorick NE (2007) The value of specific MRI features in the evaluation of suspected placental invasion. Magn Reson Imaging 25:87–93

  63. 63.

    Masselli G, Brunelli R, Casciani E et al (2008) Magnetic resonance imaging in the evaluation of placental adhesive disorders: correlation with color Doppler ultrasound. Eur Radiol 18:1292–1299

  64. 64.

    Levine D, Hulka CA, Ludmir J, Li W, Edelman RR (1997) Placenta accreta: evaluation with color Doppler US, power Doppler US, and MR imaging. Radiology 205:773–776

  65. 65.

    Dwyer BK, Belogolovkin V, Tran L et al (2008) Prenatal diagnosis of placenta accreta: sonography or magnetic resonance imaging? J Ultrasound Med 27:1275–1281

  66. 66.

    Baughman WC, Corteville JE, Shah RR (2008) Placenta accreta: spectrum of US and MR imaging findings. Radiographics 28:1905–1916

  67. 67.

    Masselli G, Gualdi G (2013) MR imaging of the placenta: what a radiologist should know. Abdom Imaging 38:573–587

  68. 68.

    Plauche W, Von Almen W, Muller R (1984) Catastrophic uterine rupture. Obstet Gynecol 64:792–793

  69. 69.

    Ofir K, Eyal S, Levy A, Katz M, Mazor M (2004) Uterine rupture: differences between a scarred and an unscarred uterus. AJR Am J Roentgenol 191:425–429

  70. 70.

    Bedi DG, Solomon A, Winsett MZ, Fagan CJ, Kumar R (1986) Ruptured uterus: sonographic diagnosis. J Clin Ultrasound 14:529–533

  71. 71.

    Omers R, Ulbrich R, Schauer A, Kuhn W (1988) Sonographic detection of an asymptomatic rupture of the uterus due to necrosis during the third trimester. Int J Gynecol Obstet 26:279–284

  72. 72.

    Vaknin Z, Maymon R, Mendlovic S, Barel O, Herman A, Sherman D (2008) Clinical, sonographic, and epidemiologic features of second- and early third-trimester spontaneous antepartum uterine rupture: a cohort study. Prenat Diagn 28:478–484

  73. 73.

    Teunissen KK, Lopriore E, Nijman RGW, Brouwer PA, van Kamp IL (2007) Silent uterine rupture, an unusual cause of anhydramnios. Am J Obstet Gynecol 196:8–9

  74. 74.

    Rozenberg P, Goffinet F, Phillippe HJ, Nisand I (1996) Ultrasonographic measurement of lower uterine segment to assess risk of defects of scarred uterus. Lancet 347:281–284

  75. 75.

    Cheung VY (2005) Sonographic measurement of the lower uterine segment thickness in women with previous Caesarean section. J Obstet Gynaecol Can 27:674–681

  76. 76.

    Gotoh H, Masuzaki H, Yoshida A, Yoshimura S, Miyamura T, Ishimaru T (2000) Predicting incomplete uterine rupture with vaginal sonography during the late second trimester in women with prior cesarean. Obstet Gynecol 95:596–600

  77. 77.

    Bergeron M-E, Jastrow N, Brassard N, Paris G, Bujold E (2009) Sonography of lower uterine segment thickness and prediction of uterine rupture. Obstet Gynecol 113:520–522

  78. 78.

    Hasbargen U, Summerer-Moustaki M, Hillemanns P, Scheidler J, Kimmig R, Happ H (2002) Uterine dehiscence in a nullipara, diagnosed by MRI, following use of unipolar electrocautery during laparoscopic myomectomy. Hum Reprod 17:2180–2182

  79. 79.

    Hruska KM, Coughlin BF, Coggins AA, Wiczyk HP (2006) MRI diagnosis of spontaneous uterine rupture of an unscarred uterus. Emerg Radiol 12:186–188

  80. 80.

    Roche O, Chavan N, Aquilina J, Rockall A (2012) Radiological appearances of gynaecological emergencies. Insights Imaging 3:265–275

  81. 81.

    Chiang G, Levine D (2004) Imaging of adnexal masses in pregnancy. J Ultrasound Med 23:805–819

  82. 82.

    Bromley B, Benaccerraf B (1997) Adnexal masses during pregnancy: accuracy of sonographic diagnosis and outcome. J Ultrasound Med 16:447–452

  83. 83.

    Ribic-Pucelj M, Kobal B, Peternelj-Marinsek S (2007) Surgical treatment of adnexal masses in pregnancy: indications, surgical approach and pregnancy outcome. J Reprod Med 52:273–279

  84. 84.

    Lev-Toaff AS, Coleman BG, Arger PH et al (1987) Leiomyomas in pregnancy: sonographic study. Radiology 164:375–380

  85. 85.

    Spencer JA, Forstner R, Cunha TM, Kinkel K (2010) ESUR guidelines for MR imaging of the sonographically indeterminate adnexal mass: an algorithmic approach. Eur Radiol 20:25–35

  86. 86.

    Smorgick N, Pansky M, Feingold M et al (2009) The clinical characteristics and sonographic findings of maternal ovarian torsion in pregnancy. Fertil Steril 92:1983–1987

  87. 87.

    Stark JE, Siegel MJ (1994) Ovarian torsion in prepubertal and pubertal girls: sonographic findings. AJR Am J Roentgenol 163:1479–1482

  88. 88.

    Rosado WM Jr, Trambert MA, Gosink BB, Pretorius DH (1992) Adnexal torsion: diagnosis by using Doppler sonography. AJR Am J Roentgenol 159:1251–125

  89. 89.

    Rha SE, Byun JY et al (2002) CT and MR imaging features of adnexal torsion. Radiographics 22:283–294

  90. 90.

    Webb EM, Green GE, Scoutt LM (2004) Adnexal mass with pelvic pain. Radiol Clin North Am 42:329–348

  91. 91.

    Kawakami S, Togashi K, Konishi I et al (1994) Red degeneration of uterine leiomyoma: MR appearance. J Comput Assist Tomogr 18:925–928

  92. 92.

    Ueda H, Togashi K, Konishi I (1999) Unusual appearances of uterine leiomyomas: MR imaging findings and their histopathologic backgrounds. Radiographics 19:131–145

  93. 93.

    Andreoiu M, MacMahon R (2009) Renal colic in pregnancy: lithiasis or physiological hydronephrosis? Urology 74:758–761

  94. 94.

    Shokeir AA, Mahran MR, Abdulmaaboud M (2000) Renal colic in pregnant women: role of renal resistive index. Urology 55:344–347

  95. 95.

    Deyoe LA, Cronan JJ, Breslaw BH et al (1995) New techniques of ultrasound and color Doppler in the prospective evaluation of acute renal obstruction: do they replace the intravenous urogram? Abdom Imaging 20:58–63

  96. 96.

    Wachsberg RH (1998) Unilateral absence of ureteral jets in the third trimester of pregnancy: pitfall in color Doppler US diagnosis of urinary obstruction. Radiology 209:279–281

  97. 97.

    Lee JY, Kim SH, Cho JY, Han D (2001) Color and power Doppler twinkling artifacts from urinary stones: clinical observations and phantom studies. AJR Am J Roentgenol 176:1441–1445

  98. 98.

    Deyoe LA, Cronan JJ, Breslaw BH, Ridlen MS (1995) New techniques of ultrasound and color Doppler in the prospective evaluation of acute renal obstruction: do they replace the intravenous urogram? Abdom Imaging 20:58–63

  99. 99.

    Spencer JA, Chahal R, Kelly A, Taylor K, Eardley I, Lloyd SN (2004) Evaluation of painful hydronephrosis in pregnancy: magnetic resonance urographic patterns in physiological dilatation versus calculous obstruction. J Urol 171:156–160

  100. 100.

    Roy C, Saussine C, Jahn C et al (1995) Fast imaging MR assessment of ureterohydronephrosis during pregnancy. Magn Reson Imaging 13:767–772

  101. 101.

    Verswijvel G, Vandecaveye V, Gelin G et al (2002) Diffusion-weighted MR imaging in the evaluation of renal infection: preliminary results. JBR-BTR 85:100–103

  102. 102.

    White WM, Zite NB, Gash J et al (2007) Low-dose computed tomography for the evaluation of flank pain in the pregnant population. J Endourol 21:1255–1260

  103. 103.

    Tamir IL, Bongard FS, Klein SR (1990) Acute appendicitis in the pregnant patient. Am J Surg 160:571–576

  104. 104.

    Gilo NB, Amini D, Landy HJ (2009) Appendicitis and cholecystitis in pregnancy. Clin Obstet Gynecol 52:586–596

  105. 105.

    Jeffrey RB, Jain KA, Nghiem HV (1994) Sonographic diagnosis of acute appendicitis: interpretive pitfalls. AJR Am J Roentgenol 162:55–59

  106. 106.

    Lim HK, Bae SH, Seo GS (1992) Diagnosis of acute appendicitis in pregnant women: value of sonography. AJR Am J Roentgenol 159:539–542

  107. 107.

    Rettenbacher T, Hollerweger A, Macheiner P et al (2001) Outer diameter of the vermiform appendix as a sign of acute appendicitis: evaluation at US. Radiology 218:757–762

  108. 108.

    Israel GM, Malguria N, McCarthy S et al (2008) MRI vs. ultrasound for suspected appendicitis during pregnancy. J Magn Reson Imaging 28:428–433

  109. 109.

    Pedrosa I, Levine D, Eyvazzadeh AD, Siewert B, Ngo L, Rofsky NM (2006) MR imaging evaluation of acute appendicitis in pregnancy. Radiology 238:891–899

  110. 110.

    Pedrosa I, Lafornara M, Pandharipande PV et al (2009) Pregnant patients suspected of having acute appendicitis: effect of MR on negative laparotomy rate and appendiceal perforation rate. Radiology 250:749–757

  111. 111.

    Cobben LP, Groot I, Haans L, Blickman JG, Puylaert J (2004) MRI for clinically suspected appendicitis during pregnancy. AJR Am J Roentgenol 183:671–675

  112. 112.

    Pedrosa I, Zeikus EA, Levine D et al (2007) MR imaging of acute right lower quadrant pain in pregnant patients and nonpregnant patients. Radiographics 27:721–753

  113. 113.

    Singh AK, Desai H, Novelline RA (2009) Emergency MRI of acute pelvic pain: MR protocol with no oral contrast. Emerg Radiol 16:133–141

  114. 114.

    Masselli G, Brizi MG, Menchini L, Minordi L, Vecchioli Scaldazza A (2005) Magnetic Resonance Enteroclysis imaging of Crohn’s. Radiol Med 110:221–233

  115. 115.

    McKenna DA, Meehan CP, Alhajeri AN, Regan MC, O’Keeffe DP (2007) The use of MRI to demonstrate small bowel obstruction during pregnancy. Br J Radiol 80:e11–14

  116. 116.

    Masselli G, Gualdi G (2012) MR imaging of the small bowel. Radiology 264:333–348

  117. 117.

    Lu EJ, Curet MJ, El-Sayed YY et al (2004) Medical versus surgical management of biliary tract disease in pregnancy. Am J Surg 188:755–759

  118. 118.

    Ralls PW, Colletti PM, Lapin SA et al (1985) Real-time sonography in suspected acute cholecystitis: prospective evaluation of primary and secondary signs. Radiology 155:767–771

  119. 119.

    Simeone JF, Brink JA, Mueller PR et al (1989) The sonographic diagnosis of acute gangrenous cholecystitis: importance of the Murphy sign. AJR Am J Roentgenol 152:289–290

  120. 120.

    Oto A, Ernst R, Ghulmiyyah L et al (2009) The role of MR cholangiopancreatography in the evaluation of pregnant patients with acute pancreaticobiliary disease. Br J Radiol 82:279–285

  121. 121.

    Tang SJ, Mayo MJ, Rodriguez-Frias E et al (2009) Safety and utility of ERCP during pregnancy. Gastrointest Endosc 69:453–461

  122. 122.

    Barton JR, Sibai BM (1996) Hepatic imaging in HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count). Am J Obstet Gynecol 174:1820–1825

  123. 123.

    Castro MA, Ouzounian JG, Colletti PM, Shaw KJ, Stein SM, Goodwin TM (1996) Radiologic studies in acute fatty liver of pregnancy. A review of the literature and 19 new cases. J Reprod Med 41:839–844

  124. 124.

    Wei Q, Li Z, Liu X (2010) Clinical diagnosis and treatment of acute fatty liver of pregnancy: a literature review and 11 new cases. J Obstet Gynaecol Res 36:751–756

  125. 125.

    Usta IM, Barton JR, Amon EA, Gonzalez A, Sibai BM (1994) Acute fatty liver of pregnancy: an experience in the diagnosis and management of fourteen cases. Am J Obstet Gynecol 171:1342–1347

  126. 126.

    Campillo B, Bernuau J, Witz MO et al (1986) Ultrasonography in acute fatty liver of pregnancy. Ann Intern Med 105:383–384

  127. 127.

    Van Le L, Podrasky A (1990) Computed tomographic and ultrasonographic findings in women with acute fatty liver of pregnancy. J Reprod Med 35:815–817

  128. 128.

    Mabie W, Dacus J, Sibai BM, Morretti ML, Gold RE (1988) Computed tomography in acute fatty liver of pregnancy. Am J Obstet Gynecol 158:142–145

  129. 129.

    Farine D, Newhouse J, Owen J, Fox HE (1990) Magnetic resonance imaging and computed tomography scan for the diagnosis of acute fatty liver of pregnancy. Am J Perinatol 7:316–318

  130. 130.

    Shah KH, Simons RK, Holbrook T et al (1998) Trauma in pregnancy: maternal and fetal outcomes. J Trauma 45:83–86

  131. 131.

    Connolly AM, Katz VL, Bash KL et al (1997) Trauma and pregnancy. Am J Perinatol 14:331–336

  132. 132.

    Sadro C, Bernstein MP, Kanal KM (2012) Imaging of trauma: part 2, abdominal trauma and pregnancy – a radiologist's guide to doing what is best for the mother and baby. AJR Am J Roentgenol 199:1207–1211

Download references

Author information

Correspondence to Gabriele Masselli.

Synopsis and key recommendations for imaging pregnant patients with acute abdominal and pelvic pain

Synopsis and key recommendations for imaging pregnant patients with acute abdominal and pelvic pain

  1. 1.

    Imaging techniques

    • Ultrasound remains the primary imaging investigation because of availability and portability, but it can be limited because of altered body habitus, small field of view and the presence of interfering overlying structures.

    • MRI helps differentiate causes of abdominopelvic pain when ultrasound is inconclusive.

    • Following severe trauma, CT cannot be delayed because of radiation concerns.

  2. 2.

    Optimal MR protocol

    • Breath hold multiplanar T2-weighted sequences based on the half-Fourier reconstruction technique, and the balanced gradient-echo sequences and axial and sagittal T1-weighted GRE and diffusion sequences.

  3. 3.

    Recommendations for clinical practice

Placental abruption

MRI should be considered after negative ultrasound findings when there is high clinical suspicion and when a firm diagnosis of abruption would change clinical management.

Placenta adhesive disorders

Ultrasound in patients with clinical risk factors and then proceeding to MR imaging for equivocal cases especially in patients with posterior placenta and previous myomectomy.

Uterine rupture

MRI to diagnose ante-partum uterine rupture in patients with indeterminate ultrasound evidence, showing the tear itself and other uterine wall defects including uterine dehiscence.

Adnexal mass

Most masses can be accurately assessed by ultrasound; however, MR imaging can provide further characterisation, particularly for evaluating their haemorrhagic content.


Ultrasound is accurate in most cases. Perform MRI if any difficulty differentiating from an adnexal mass.

Ovarian torsion

Magnetic resonance imaging should be performed after inconclusive ultrasound and can detect hemorrhagic infarction.


Ultrasound is the first imaging test despite its substantial limitations.

Magnetic resonance urography (MRU) differentiates physiological urinary tract dilatation from abnormal dilatation related to urolithiasis.

In unresolved cases, CT remains a reliable technique for depicting obstructing urinary tract calculi in pregnant women.


Ultrasound can be limited by the pregnant body habitus, especially in the later stages of gestation. MR should be performed in case of inconclusive ultrasound.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Masselli, G., Derchi, L., McHugo, J. et al. Acute abdominal and pelvic pain in pregnancy: ESUR recommendations. Eur Radiol 23, 3485–3500 (2013).

Download citation


  • Acute abdominal pain
  • Pregnancy
  • Guidelines
  • Ultrasound
  • Magnetic resonance